Health is facing some big challenges that require the input of whole systems to solve, but when a problem is this big – where do you start?

In this blog, HIEM, Senior Improvement Lead, Kate Hardiman describes how we supported Joined Up Care Derbyshire to reduce harm from opioids for local patients, using a 7-step approach to working across whole systems.

The project, which has been shortlisted for the HSJ Patient Safety Awards, trained 80 Live Well With Pain practitioners, potentially saved five lives, and saw 131 fewer people prescribed high dose opioids and 306 fewer people with chronic opioid use.

 Approximately 8million adults in the UK report chronic pain that is moderate to severely disabling. Many are prescribed opioids. We estimate that for every 62 people who stop (or do not start) an opioid one life will be saved.

In 2022, as part of our national Medicines Safety Improvement Programme with NHS England, we began a collaboration with Joined Up Care Derbyshire to reduce the harm from opioids for chronic non-cancer pain (CNCP).

We identified a population of 20,722 people in Derby and Derbyshire who had been prescribed opioids for longer than three months (Sept 2024, NHS BSA).

Evidence shows high-dose opioids are ineffective in CNCP. Reducing from high dose opioids (>120mg) to a lower dose can reduce a persons mortality by 50% (MedSIP Methodology Report, 2022).

The collaboration ambition was for Derby and Derbyshire to adopt a system wide approach due to the pervasive nature to pain spanning each healthcare sector. This approach set out to improve access to pain self-care, thereby reducing opioid harms and shifting the focus away from medication and polypharmacy management.

To tackle the challenge we worked together to use the 7 step whole systems approach to change. We achieved a 50% reduction in mortality for 306 patients between 2022-2025.

The 7-step approach incorporates:

Phase 1 - Set up

This phase sets up the aims of the programme. National scoping was undertaken prior to the launch of this programme and 5 themes had been outlined as target areas for improvement: Prevent initiation of opioids, De-escalation, Find chronic use, Treat (taper & support) and Sustain.

Phase 2 and 3 - Building the ICS picture and System mapping

We spent time at the start of the project stakeholder mapping and building a compelling narrative to create a shared understanding of how CNCP could be addressed at an ICS level.

This included collecting national, local and practice level data that was reflective of health inequalities and service provision.

We ran local events to enable early involvement of local communities and those with lived experience to raise issues and contribute to action planning. We established what other commissioned non-pharmacological support was available and helped identify advocates and examples of good practice.

Skills and service need assessment was carried out across the Pharmacy profession and was then reviewed and improved by the system to form the basis of the next phase; action planning.

Phase 4 - Action planning

Stakeholders were brought together to prioritise areas and propose collaborative and aligned action. A single online action planning event was held involving key stakeholders, decision makers and lived experience.

Issues, solutions and actions raised throughout the session were prioritised into short- and long-term goals. This was repeated three times and once agreed, engaged attendees committed to attend working groups and a clear mandate was outlined.

Phase 5 - Managing the network

Three working groups were set up in Derby and Derbyshire (Core Group, Transfer of Care and Pain Initiatives Working group).

They focussed on:

• developing resources/guidelines for tapering and repeat prescribing of opioids.
• embedding the policy for Discharge Medicines Service (DMS) in secondary care.
• provision of funding to increase trained practitioners in LWWP.
• adoption and spread of pain support groups with the use of resources developed.
• local website development and building relationships across the county.
• creation of a ‘Community of Practice’ to run shared learning events with facilitators of the pain support group.

Phase 6 - Action

This phase sees all the planning in the previous phases start to produce products. With JUCD we:

• monitored local and national data to spot trends and assess impact via ePACT and the National Dashboard.
• analysed DMS data in secondary care to establish re-admission avoidance and audit the discharge policy.
• audited the discharge work at two acute sites which is suggestive of 599 admissions avoided across the system.
• funded a social media campaign to increase traffic to the JUCD website where information is held regarding non-pharmacological support in primary care.

And the following resources were produced to allow sustainability and further adoption and spread to other ICS.

• Opioid Prescribing Quality Improvement Toolkit for Primary care
• Educational webinars delivered
• An appreciative inquiry report on the 21 local chronic pain support groups
• Development of a Facilitator Guide in collaboration with LWWP to aid delivery
• Development of an Implementation Guide in collaboration with LWWP to aid the adoption and spread.
• A quantitative data spreadsheet was created to collect quantitative data to support the evidence for sustainability of the groups moving forward.
• Two digital tools were developed to support consultation/medication review meetings for those receiving opioids for the management of CNCP that can be embedded into SystmOne (see case study)
• Positive patient stories

Phase 7 - Quality Improvement to Quality Control (sustainability)

Sustainability of such a large project is key to ensuring the ICS and local population see the best results for all their work.

For Derby and Derbyshire, sustainability planning to prepare for when HIEM and the EMPSC stepped back, started in October 2024. A shared ownership approach was agreed with leadership of the programme housed within the MSK pathway ensuring ongoing service provision of the pain support groups. Sharing of resources will sit with ‘Place & Partnerships’ and guidelines and policies will remain under the ownership of the Medicines Optimisation team.

The 7 steps approach proved a successful methodology to working across whole systems and we are continuing to use it in the new 25/26 MedSIP project this year. We’ve shared some top tips below to consider if you are embarking on a similar transformation:

• Have an idea/agreed long term home for a programme at the start of a programme.
• High level, Board buy-in is important to ensure the work continues when times get tough.
• Decide where project ownership sits – in this case, project ownership remained with the ICB; with EMPSC is an enabler and supporter.
• Involvement of voluntary sector and non-NHS badged services is crucial.
• Identify and work within identified constraints and acknowledge them.
• Involve a Clinical Advisor / Partner in the programme such as Dr Roger Knaggs to enable navigation and sense checking direction and resource creation whilst aligning with national and government priorities.
• Think about data needs early and continually check with the systems.
• Health inequality data was useful to outline populations and target areas for improvement.
• Using an Appreciative inquiry approach works (system mapping was done this way).
• Relationship building takes time and is crucial for navigating challenges.
• Finding key advocates at local, regional and national level really supports the work.

For more information on the 7 steps approach or the MedSIP programme please contact This email address is being protected from spambots. You need JavaScript enabled to view it. (could add our website here too)

“Working with the Patient Safety Collaborative has magnified system reach in relation to our Medicines Safety Improvement programme, to reduce harm from opioids, in Joined Up Care Derbyshire. The validated quality improvement methodology provided, which we can adapt for other programmes of work, was invaluable.”  Head of Medicines Management – Quality and Safety, Joined Up Care Derby and Derbyshire ICS (May 2024)

“JUCD and HIEM Patient Safety Collaborative have worked collaboratively to improve the lives of patients with chronic pain over the last three years. The HIEM have been important members of the project team and have been critical to ensuring the project progresses and improvements are identified, embedded and having a positive impact. 

The HIEM PSC team have brought a range of benefits to the project including: 

• building relationships with experts in this field (academia, clinical and third sector) 

• bringing expertise to the project from a clinical, data and project management / quality improvement perspective 

• supporting and developing a systems approach to improvement by developing a community of practice across the system. 

• advocating for people with lived experience and supporting their involvement in the work 

• providing support to maintain momentum and drive change 

It has been an absolute pleasure working with the HIEM PSC team - this has been a real team approach and they have provided energy, support, drive and  challenge to deliver measurable improvements for our patients. 

Thank you.” 

Alison Brailey, Senior Reporting Officer for the use of Opioids in the Management of CNCP in Derby and Derbyshire (March 2025)